Combination therapy of nitazoxanide with oseltamivir compared with oseltamivir in hospitalized patients with seasonal influenza.

Antiviral combinations have been proposed as treatment for influenza in order to increase the antiviral activity by action at different sites of action as well as obviate the emergence of drug resistance to the commonly used antiviral agents like oseltamivir. Nitazoxanide has been found to exhibit anti-influenza viral activity with clinical benefit in a previous study. We recruited 242 cases of SARI, among whon 67 were confirmed to have influenza viral infection. In a randomized blinded fashion, 34 patients received a combination of nitazoxanide and oseltamivir whereas 33 cases received oseltamivir alone. Clinical parameters were followed in both groups and the nasal swabs were re-tested on day 6 for influenza positivity and the cycle threshold (CT) values. No significant differences were observed in terms of time for resolution of fever, other symptoms, and SOFA scores. Nine patients succumbed during the course of the illness that included three in the oseltamivir group and six in the combination group. All but one of those who expired had an underlying co-morbid illness. Our preliminary data suggest that the addition of nitazoxanide does not improve outcomes in hospitalized patients with influenza. Larger studies are recommended for statistically robust conclusions.

Combination of vitamin C, thiamine and hydrocortisone added to standard treatment in the management of sepsis: results from an open label randomised controlled clinical trial and a review of the literature.

Background: Combination of vitamin C, hydrocortisone and thiamine have recently been used in sepsis but data of efficacy are conflicting and no data are available from developing countries. We sought to study the effect of addition of this combination to standard care in patients with sepsis/septic shock in a north Indian setting.Methods: In a prospective, open label, randomised fashion, 100 patients with sepsis/septic shock were recruited to receive either standard therapy alone (control group, n = 50) or a combination of vitamin C, thiamine and hydrocortisone (treatment group, n = 50) in addition. The patients were followed for various clinical and laboratory parameters, in-hospital and 30-day mortality, duration of vasopressor use, lactate clearance, duration of hospital stay, and change in serum lactate and the SOFA score over the first 4 days.Results: The 2 groups were matched for basic characteristics. The in-hospital mortality (28% in controls and 24% in treatment group, p = .82) and 30-day mortality (42% in controls and 40% in treatment group, p = 1.00) was not significantly different in the 2 groups. However, there was a significant difference in duration of vasopressor use (96.13 ± 40.50 h in control group v/s 75.72 ± 30.29 h in treatment group, p value = .010) and lactate clearance (control group: 41.81% v/s treatment group: 56.83%, p value =.031) between 2 groups.Conclusions: Addition of vitamin C, hydrocortisone, and thiamine into standard care of sepsis does not improve in-hospital or 30 day mortality. However lower vasopressor use and faster lactate clearance is observed with treatment.

Eventration of diaphragm with dextrocardia and type 2 respiratory failure: A rare entity.

Eventration of the diaphragm is a rare condition where the muscle is permanently elevated, but retains its continuity and attachments to costal margin. In this condition, all or part of the diaphragm is largely composed of fibrous tissue with a few or no interspersed muscle fibers. It can be complete or partial. It is seldom symptomatic and often requires no treatment. We present a 70-year-old male who came with progressive breathlessness and was admitted with type 2 respiratory failure, and on evaluation was found to have complete eventration of the left diaphragm with herniation of colon and stomach in the left chest with dextrocardia. Aim of reporting this rare case is to highlight the importance of history taking, good physical examination, and imaging in the diagnosis of diaphragmatic eventration.

Localized cutaneous mucinosis associated with multiple myeloma: a rare presentation.

Lichen myxoedematosus (LM), a form of primary cutaneous mucinosis, may present either as localized less severe form called papular mucinosis or diffuse more severe form called scleromyxoedema. The diffuse form is almost always associated with monoclonal gammopathy, whereas localized form is not. We report an atypical case of localized form of LM associated with multiple myeloma in a 66-year-old male, who presented with asymptomatic waxy papular eruption on extremities, which on histopathological examination confirmed the diagnosis of cutaneous mucinosis. After initially being put on steroids and hydroxychloroquine with minimal improvement, patient subsequently presented with encephalopathy and on evaluation revealed hypernatremia, hypercalcemia, hypergammaglobulinemia, reversal of albumin-globulin (A/G) ratio, azotemia, and lytic lesions in skull X-ray. Bone marrow aspiration and biopsy confirmed multiple myeloma. Patient was successfully treated with standard treatment regimen for multiple myeloma with bortezumib and dexamethasone and his skin lesions subsided completely.

Effects of pepper grenade explosions on non-combatant bystanders.

Pepper gas is used for riot control in many parts of the world. Yet, its effects on bystanders are largely unreported. We fielded a questionnaire-based survey of 500 bystanders exposed to gas when police used pepper grenades against belligerent 'stone-pelters' in the northern Indian state of Jammu & Kashmir. Of 294 non-combatants who consented to participate in our survey, 97 per cent developed cough and irritation of the throat within few seconds of breathing the pungent smelling gas. They reported respiratory problems, dermatologic symptoms, sleep disturbances, and mood changes with varying frequency. Sixteen reported exacerbations of underlying respiratory disorders, with one temporally related to death. Symptoms led 51 to get medical attention. Nearly all respondents reported that symptoms recurred on re-exposure. We conclude that use of pepper grenades can cause serious acute symptoms in non-combatants accidentally exposed. We recommend alternate methods of riot control - water cannons, baton charges, tasers, plastic or rubber bullets, and so on - that have no collateral side effects on non-combatants be considered for routine use.

Tubercular osteomyelitis of the mandible in a young female.

A 16-year-old female presented with a 6-month history of a gradually increasing swelling of the left side of her face. A panoramic radiographic view of the mandible showed diffuse radiolucency in the ramus of the mandible with a loss of cortication on the superior and anterior portion of the condyle. The computed tomography (CT) scan revealed destruction of the mandibular bone and a large retromandibular and inferior temporal fossa mass with areas of breakdown. The biopsy was consistent with tubercular osteomyelitis. Antitubercular therapy resulted in a marked reduction of the size of the swelling over a 9-month period.

Skin rash and subconjunctival haemorrhage in an adult with pandemic H1N1 influenza.

A young man presented with erythematous rash that appeared 3 days following upper respiratory symptoms and fever. Diffuse exanthematous rash was seen over whole body, most pronounced over the trunk. A subconjunctival haemorrhage also appeared in the left eye following incessant cough. Reverse transcription-PCR of the nasopharyngeal secretions revealed influenza A (2009 pandemic H1N1). The patient responded to oseltamivir therapy. Influenza should be considered in patients presenting with exanthematous skin rash.

Hidden diagnosis in the subglottic larynx: schwannoma mimicking as bronchial asthma.

Schwannomas are rare neurogenic tumors derived from the schwann cells. Their laryngeal location is uncommon and the diagnosis is difficult. We report a case of a 17-year-old female who presented with symptoms of intermittent breathlessness mimicking acute attacks of bronchial asthma and resulted in delayed diagnosis, which lead to upper airway obstruction and an emergency tracheostomy. Computed tomography (CT) of neck revealed a soft-tissue mass within the subglottic region. Surgical excision of the growth was done by laryngofissure technique. Histopathological examination of the tumor revealed it to be a schawanoma. The subglottic occurrence of schwannoma is very rare. Case history and detailed clinical examination are important and will guide for relevant investigations and help to reach at a definitive diagnosis.